Provider Demographics
NPI:1285790915
Name:SOUTHEAST CARDIOLOGY CLINIC INC.
Entity type:Organization
Organization Name:SOUTHEAST CARDIOLOGY CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-1929
Mailing Address - Street 1:1150 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3022
Mailing Address - Country:US
Mailing Address - Phone:334-712-1929
Mailing Address - Fax:334-712-2799
Practice Address - Street 1:1150 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-712-1929
Practice Address - Fax:334-712-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258388700Medicaid
AL529301110Medicaid
FL258388700Medicaid
AL000055299Medicare PIN
AL000088715Medicare PIN
ALI058Medicare PIN
AL529301110Medicaid
AL000055300Medicare PIN
AL000088713Medicare PIN
AL051556107Medicare PIN
GAC30943Medicare PIN
GAGRP2142Medicare PIN
AL000055301Medicare PIN
AL051558768Medicare PIN
FL24995Medicare PIN
ALF013Medicare PIN
AL000095006Medicare PIN
AL000024479Medicare PIN